What Hospitals Can Teach the Police

By Douglas Starr

Mr. Starr is a director of the graduate program in science journalism at Boston University.

April 21, 2018

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CreditCreditEiko Ojala

When a police officer in Cambridge, Mass., punched a black male Harvard student in the stomach multiple times while subduing him this month, the nation was reminded yet again of how quickly confrontations between the police and civilians can intensify beyond what the situation seems to call for. (The student was naked in public and apparently behaving erratically.)

Much of the recent conversation about police violence in the United States has focused — quite rightly — on concerns about racism and the flagrant abuse of power. But even when law enforcement seems to be acting in good faith, there is a concern about escalation. According to a recent survey by the Police Executive Research Forum, American police academies put too much emphasis on weapons, tactics and legal statutes and not enough on psychology and communication. How can police officers be better trained to remain calm and defuse tense situations?

An unexpected model comes from the field of health care, a profession that has found ways to address the incidence of violence in encounters with those it aims to serve. Hospital workers often come into contact with volatile people: agitated drug users, panic-stricken accident victims, the hysterical parents of sick or injured children and so on. Those workers report nonfatal violence-related injuries at many times the rates of members of other occupations, including law enforcement (though police officers have higher rates of fatalities).

Because health care professionals are not permitted to attack, shoot or otherwise harm patients, they have been forced to develop techniques for de-escalating potentially violent situations. In 1991, for example, Massachusetts General Hospital hired the security expert Bonnie S. Michelman to revamp its security programs. Ms. Michelman made infrastructure changes like installing closed-circuit TV and silent alarms. More important, she started teaching a de-escalation course to hospital staff members, showing them how to detect early signs of agitation and pre-empt aggression. Within a few months the hospital had reduced by more than 80 percent the number of incidents requiring physical restraint.

The overall number of reported incidents today at Massachusetts General Hospital has not fallen, but the nature of them is shifting, with fewer physical assaults and more episodes of verbal abuse. This suggests that staff members are detecting and addressing conflicts before they escalate.

At Ms. Michelman’s suggestion, I sat in on a course taught by a private company that offers de-escalation training. The instructor, a burly former Pennsylvania state trooper named George Kadash, conceded that quick and decisive action is sometimes required, and he showed us physical techniques for restraining people without harming them or ourselves. But he stressed that it is often better to step back, reassess and then re-engage at a calmer emotional level or with greater resources — what the British police call a “tactical pause.”

Mr. Kadash taught us to read body language and facial expressions so we could anticipate when things might escalate to the point of physical danger. He taught us about personal space and the “reactionary gap,” a distance that puts you close enough to listen but far enough to give you to time react.

De-escalation does not mean giving in to someone who is disobeying the rules, Mr. Kadash explained. Rather, it means calmly and firmly asserting the rules while acknowledging the other person’s humanity.

We learned from Mr. Kadash never to say “calm down” or to justify an action by saying “it’s policy,” which almost always inflames a situation. We learned to refer not to “your” problem but instead to “a” problem, and to speak in terms of a collective solution. For example: “I understand there is an issue here. How can we solve it?” We learned never to point with your index finger: It’s accusatory, even when indicating a direction. Instead, we learned to direct with the sweep of an open hand, like a maître d’ saying, “Right this way.”

At the Boston University Medical Center, security staff members teach a kind of tactical pause to residents and fourth-year medical students who do home visits. Constance L. Packard, executive director of support services for the center, told me, “Sometimes if the patient gets too anxious we’ll teach a person to say, ‘Let me get right back to you, because I need to go get a Form 9.’ ”

“There’s no such thing as a Form 9,” Ms. Packard continued. “It’s just a way of stopping the action.”

Lynn Van Male, the director of violence prevention for the Department of Veterans Affairs hospital system, emphasizes the importance of using de-escalation techniques with veterans who were trained to use force, many of whom were traumatized in violent settings. (A regulation passed in 2010 makes it illegal for a V.A. hospital to turn away a veteran regardless of how violent he or she may be.)

Dr. Van Male and her predecessors created a program that involves anticipating incidents by flagging the electronic file of a patient who has been violent in the past or otherwise demonstrated a risk of violence. That information goes to a threat-assessment team, which alerts staff members in advance of appointments. The V.A. also works with crash dummies at a biomechanics lab to develop physical techniques that suppress violence while not harming the patient or staff.

In the last couple of years, the Police Executive Research Forum, the International Association of Chiefs of Police and other police organizations have expressed public support for de-escalation as a necessary part of police training. Seventeen states have passed laws requiring de-escalation training for police officers (nine of them did so after the 2014 shooting and protests in Ferguson, Mo.), and several departments, including those in Salt Lake City, Nashville and Philadelphia, have independently adopted the practice.

Yet large-scale implementation is another matter. Unlike in Britain, where all police officers receive de-escalation training, there is no central police authority in the United States to set national policy. With 18,000 independent police departments, most of which have 50 members or fewer, it is hard to establish a practice that every department and officer will accept.

There is also a cultural obstacle to overcome, says Chuck Wexler, the executive director of Police Executive Research Forum: a warrior-like mind-set that an officer should never retreat. “We’re not advocating walking away from a situation,” Mr. Wexler told me. “But if something fails it’s O.K. to step back, have a tactical pause and come up with a Plan B. The sanctity of human life should trump everything.”